A Three Year Review of Federal Inmate Suicides (2011 - 2014)


  • Suicide is the leading cause of un-natural death in federal prisons, accounting for about one-in-five deaths in custody in any given year. 
  • Every year, approximately ten federal inmates commit suicide.  While the rate of prison suicide has generally been declining, it is still seven times higher than in the general population. 

Why We Did this Review

  • The Correctional Service of Canada (CSC) has an obligation to preserve life in custody.   A number of recent developments, including the disproportionate number of prison suicides that continue to occur in segregation cells, suggest that progress in preventing deaths in federal custody has stalled, prompting the Office to conduct an independent review. 

What We Did

  • The Office conducted a review of 30 inmate suicides that occurred in federal penitentiaries in the three year period between April 2011 and March 2014. 
  • The Office reviewed the current literature on prison suicide, analyzed CSC’s investigative reports of suicides for the period under review, assessed the Service’s suicide awareness and prevention strategy, and reviewed records from provincial and territorial inquests and fatality inquiries involving federally sentenced inmates.
  • Case summaries of the circumstances and events leading up to ten suicide deaths were also prepared; these cases were purposefully selected to illustrate recurring issues in preventing suicide in a correctional context.

What We Found

  • Most federal inmates who commit suicide are unmarried, Caucasian males between the ages of 31-40.  Most prison suicides occur in medium security institutions, nearly always in cells and often when staffing levels are low.  The most common method of prison suicide is by hanging. 
  • 14 of the 30 suicides reviewed occurred in segregation cells.  This high proportion is indicative of CSC’s continued reliance on segregation as a means to manage mentally ill, suicidal and self-harming individuals.
  • In the majority of cases, there were either known immediate events, risks or circumstances that indicated suicidal intent.  Most had previously attempted suicide, most had a documented mental health issue and/or concurrent substance abuse disorder.  Suicide notes were found in 14 cases, suggesting that suicidal intent had been formed in advance.  Post-incident investigative reports suggest that precipitating events, indicators or risks of suicide are often missed, ignored or not taken seriously at the time of the incident. 
  • There are considerable gaps in CSC’s investigative and review process that significantly impedes progress in preventing deaths in custody:
    • Internal investigations are too narrow focused on policy and procedural compliance and do not pay enough attention to prevention.
    • Most investigations fail to go the extra step to identify how the death might have been averted had staff acted or decided in a different manner.
    • Lessons learned from one incident are not widely shared and little has been done to examine findings in their totality.
    • CSC staff members investigating other CSC staff lack both functional and organizational independence. 
  • Preventing deaths in custody is challenging work, but it is not beyond the reach of a comprehensive prison suicide awareness and prevention program.  The report concludes that some of the suicides could have been averted through:
    • More rigorous screening procedures.
    • A coordinated national effort to manage the identification and or removal of in-cell suspension points.
    • Better information sharing.
    • More timely access to mental health services.

What We Recommend

To aid in the prevention of future suicide deaths in custody, the report makes eleven new recommendations, among them:

  1. As a matter of immediate priority, CSC should remove all known suspension points in segregation cells across the country.  Where this is deemed technically or economically unfeasible, such cells (or ranges) should be decommissioned. 
  2. Long-term segregation of seriously mentally ill, self-injurious or suicidal inmates should be expressly prohibited.
  3. A national effort, led by Health Services, should identify inmates at elevated risk of suicide who are held in long-term segregation or have a history of repeated placements and develop appropriate mitigating measures to be shared with operational sites.
  4. The Regional Complex Mental Health Committees should directly oversee the treatment and management plans of inmates on active suicide watch or mental health monitoring placed in segregation, observation, psychiatric or behavioural cells.
  5. CSC should routinely share boards of investigations with designated family members as well provincial and territorial Coroner and Medical Examiner Offices regardless of whether the death goes to inquest or public fatality inquiry.

The report also reiterates a previous recommendation by the Office: “The Minister of Public Safety should create an independent national advisory forum drawn from experts, practitioners and stakeholder groups to review trends, share lessons learned and suggest research that will reduce the number and rate of deaths in custody in Canada.”  (2012-13 Annual Report of the Office of the Correctional Investigator).